Arizona Annual Tuberculosis Surveillance Report 2015 Table of Contents I. Executive Summary 1 II. Report Highlights 2 III. Case Rates 3 IV. Cases and Case Rates by Race and Ethnicity 4 V. Cases by Gender 4 VI. Cases and Case Rates by Age Groups 4 VII. Case Rates by Nativity and Country of Origin 5 VIII. HIV Co-infection and HIV Testing Status 5 IX. TB Cases Diagnosed in Correctional Facilities 5 X. TB Risk Factors 6 XI. TB Drug Resistance Patterns 6 XII. Directly Observed Therapy 6 XIII. Completion of Treatment 7 XIV. Contact Investigation Data 7 XV. International Referrals and Class B’s 8 XVI. Conclusion 9 I. Executive Summary The Arizona Department of Health Services’ (ADHS) Tuberculosis Control Program (the Department) conducts surveillance, data analysis, program evaluation, and consultation for health care providers, health care facilities, and Arizona’s tribal and local health departments (LHDs). Close collaboration with the Arizona State Public Health Laboratory (ASPHL), ensures appropriate laboratory testing for specimens and monitoring drug-resistance patterns in the state. Arizona is comprised of fifteen counties and twenty-one federally recognized tribes. The LHDs provide direct patient care for tuberculosis (TB) control activities. The LHDs coordinate with various medical providers and correctional health staff members within their jurisdiction to provide TB control and prevention services. The ASPHL provides comprehensive testing services including acid-fast bacillus (AFB) smear, culture, nucleic acid amplification, identification, and drug susceptibility testing for clinical mycobacterial samples statewide. The laboratory serves as a reference laboratory for all isolates suspected to be positive for TB and performs drug susceptibility testing for all first–time positive isolates. The laboratory also sends isolates to the Centers for Disease Control and Prevention (CDC) contract lab in Michigan for genotyping of all positive culture isolates. This report provides information about Arizona’s reported TB cases in 2015 and completion of treatment data for 2013. The latest year for completion of treatment information available is 2013 due to length of time needed to successfully complete TB treatment. 1 II. Report Highlights  Cases of active TB disease reported in Arizona totaled 198 in 2015. The 2015 TB case rate in Arizona was 2.9 per 100,000 population compared to 3.0 per 100,000 nationally.  Completion of treatment has been a targeted focus of the Department. The latest year for which completion of treatment data is available is 2013. The completion of treatment for both correctional and non-correctional TB cases remained steady. Non-Correctional TB Cases 2012 2013 98% 97% Correctional TB Cases  Risk factors identified for all Arizona TB cases include: • Country of birth other than the U.S • Diagnosed while in a correctional facility 20% 71% 16% 6% • Diabetes mellitus • HIV co-infection  Drug susceptibility testing was reported for 100% (147/147) of the culture positive TB cases.  11.6% (17/147) reported isoniazid (INH) resistance.  2 cases of multi-drug resistance (MDR) were reported. 2012 2013 94% 93%  Continuity of care for active TB cases who return to their home country is achieved with international referrals via CureTB and TBNet, part of MCN (Migrant Clinicians Network)  These agencies provide assistance to TB cases for medical case management and continuity of care. The Department coordinates Meet and Greets through the Ports of Entry of Nogales and San Luis for cases returning to Mexico. These Meet and Greets are coordinated with the Office of Border Health, LHDs, ADHS TB Control, correctional facilities and the health department in Mexico. In 2015, fifteen meet and greets were arranged. 2 III. Case Rates TB Cases and Case Rates in Arizona and Nationally, 2006-2015 Selected Number of TB Cases, Arizona 2015 Total Arizona: 198 Maricopa County: 95 cases Pima County: 36 cases Pinal County: 32 cases Yuma County: 19 Cases In 2015, Arizona’s LHDs reported 198 cases of active TB with a case rate of 2.9 per 100,000. This represents a 2.6% increase in the number of cases and level case rate compared to 2014. In the U.S., a total of 9,563 TB cases were reported in 2015 with a case rate of 3.0 per 100,000. This was the first national increase in TB incidence since 1992. TB Case Rates by Selected Population Groups, Arizona, 2015 In 2015, the TB case rate among foreign-born individuals was 15.3 per 100,000. The case rate among U.S.–born persons was 1.1 per 100,000. Among U.S.–born Non-Hispanic blacks, the rate was 2.0 per 100,000. TB case rates among children less than five years of age was 1.9 per 100,000. All case rates increased except foreign-born TB cases. Four of Arizona’s fifteen counties Maricopa, Pinal, Pima and Yuma comprised 92% (182/198) of active TB cases reported. A full list of TB cases and case rates can be found on the Arizona Tuberculosis Program’s Webpage. TB Case Rates by County, Arizona, 2015 The statewide TB case rate, represented by the bright green line, was exceeded in Apache, Pinal, Pima and Yuma counties. Maricopa County, Arizona’s most populous county reports around 50% of the states TB cases annually. Their case rate had a slight increase from 2.3 in 2014 to 2.4 in 2015. In 2015, there were no cases reported in Graham, Greenlee, La Paz or Navajo 3 counties. Also to note, all but one of the TB cases reported in Pinal County was diagnosed within a correctional facility. There are twenty-one correctional facilities located within Pinal County, including U.S. Immigrations and Customs Enforcement Service Processing Centers (ICE-SPC), federal, state, local and privately managed facilities. The highest rate among racial/ethnic groups was reported for TB patients of Asian descent, followed by African-Americans then Hispanics. This follows previous year’s trends. V. Cases by Gender TB Cases by Gender, Arizona, 2015 IV. Cases and Case Rates by Race and Ethnicity Number of TB Cases by Race and Ethnicity, Arizona, 2015 25 Males: 139 19 97 14 43 Hispanic Asian Non-Hispanic Whites Black/African American Native American Hispanic ethnicity of any race accounts for almost half of all reported TB cases annually. The second largest number of TB cases comes from people of Asian descent. Case Rates by Race and Ethnicity, Arizona, 2011-2015 In 2015, males accounted for 70% of active TB cases compared to 30% for females. This is consistent with nationwide and previous years’ surveillance data. VI. Cases and Case Rates by Age Groups Number of TB Cases and Case Rates by Age Groups, Arizona 2015 65+ 65+ 47 cases 4.6 45-64 45-64 57 cases 20 2011 Females: 59 2012 2013 2014 2015 15 25-44 56 cases 15-24 24 cases 3.5 25-44 3.3 15-24 5-14 2.6 5-14 5 6 cases 0-4 0.7 0-4 0 8 cases 1.8 10 Black or AfricanAmerican Non-Hispanic White Native American Asian Hispanic In 2015, the largest number of cases was in the age group 45-64, followed by 25-44 then 4 those aged 65+. The highest case rates fall in the 65 or older case rate followed by 45-64 then 25-44. Percentage of TB Cases with HIV Coinfection and % HIV Results Known, Arizona, 2011 -2015 VII. Case Rates by Nativity and Country of Origin TB Cases by Nativity, Arizona 2015 U.S. born Foreign-Born 57 141 In 2015, 71.2% (141/198) of the TB cases were identified as foreign-born cases. U.S.born TB cases accounted for 28.8% (57/198) of total reported cases. For TB surveillance purposes, a U.S.-born person is defined as someone born in the United States or its associated jurisdictions. It also includes someone born in a foreign country, but with at least one U.S.-citizen parent. 6 cases 4 cases Guatemala 9 cases China IX. TB Cases Diagnosed in Correctional Facilities India 14 cases Philippines 57 cases United States 70 Cases Mexico Highest Burden Countries for TB Cases in Arizona, 2015 In 2015, HIV co-infection reached a 5-year high with 5.7% of TB cases being co-infected. HIV is the strongest known risk factor for TB disease. The Department recommends that medical providers provide HIV counseling and testing for all TB patients. Co-infection with HIV and TB in individuals is a major concern because immunosuppression caused by HIV can negatively impact the body’s ability to fight infection. Individuals with coinfection have high mortality rates and can develop drug resistance. This potentially leads to longer and more complex treatment regimens. TB Cases Diagnosed in a Correctional Facility, Arizona, 2011-2015 81% (160/198) of the cases came from the above countries. The remaining 38 cases came from several countries in Africa, Southeast Asia, the Middle East, and South America, but are represented by 3 cases or less. VIII. HIV Co-infection and HIV Testing Status 5 Arizona has consistently ranked as one of the highest states in the nation for percentage of TB cases diagnosed while incarcerated. In 2015, among reported cases over the age of fourteen, 20% resided in a correctional facility at time of diagnosis. Routine evaluation of all inmates for TB during the intake process allows for diagnosis of both latent TB infection (LTBI) and active TB in this population. The Department works together with LHDs to provide correctional health staff with TB training and education to ensure facilities abide by inmate screening requirements. X. TB Risk Factors TB Cases by Selected Risk Factors, Arizona, 2015 71% 20% 17% 16% 8% 6% 6% 4% 4% 3% •Country of birth other than the US •Diagnosed while in a correctional facility •Any Substance abuse •Diabetes mellitus TB Cases Reported with Drug Sensitivity and Drug Resistance, Arizona, 2015 Any INH Resistance MDR TB 1.0% Other Resistance Total Resistance 11.6% (2 cases) 13.2% 24.5% In 2015, 74.2% (147/198) of cases had culture positive results. Of these cases, 100% reported drug sensitivity results. Drug resistance in Arizona has been slowly increasing in Arizona. 2015 had the highest percentage of total resistance. Almost 1 in 4 TB cases had some sort of drug resistance. XII. Directly Observed Therapy Directly Observed Therapy, Arizona, 2011-2013 •Contact of Infectious TB Patient <2 years •HIV co-infection •Homeless within past year •Migratory Agricultural Worker 92.3% 2011 100% 96.6% 2013 2012 •Healthcare worker •Incomplete LTBI Therapy XI. TB Drug Resistance Patterns Directly observed therapy (DOT) is the standard of care for administering TB medications to active cases. In DOT, health care workers observe the individual take his/her medications to ensure compliance with the treatment regimen. All LHDs are encouraged to provide DOT for community cases. DOT can be difficult for some of 6 Arizona’s LHDs as most of the rural counties are large and require long distance travel to provide this service. Video DOT (vDOT) is being utilized by more and more LHDs in Arizona. The effectiveness of LHD efforts is demonstrated by the results for 2013, where no cases only self-administered medications. XIII. Completion of Treatment Completion of Treatment for Correctional vs. Non-Correctional TB Cases, Arizona, 2009-2013 100 94.1 97.7 82.7 80 86.7 86.3 Sputum-Smear Postive TB Contact Investigations, Arizona, 2013 59.1 53 out of 62 Cases with Contacts 39.4 20 0 XIV. Contact Investigation Data 72.3 60 40 90.9 90.7 The denominator does not include cases which moved out of the U.S. during treatment. The Department has been focusing on improving treatment completion through close collaboration with the Pinal County TB Program. Most of Arizona’s correctional cases reside in Pinal County. Pinal County has made big strides in improving collaboration with the correctional facilities in 2015. 1158 out 2646 Contacts Evaluated 2009 2010 Correctional 2011 2012 Non-Correctional 2013 Completion of treatment for TB cases is a continuing focus for the Department. The overall goals for treatment of TB are to cure the individual patient and limit the transmission of TB to other people. Thus, successful treatment of each individual TB patient benefits the individual and the community. The Department conducted cohort reviews and collaborated with LHDs which improved completion of treatment in Arizona for noncorrectional cases. Also, the Department utilizes international referrals to provide completion of treatment information for TB cases that have left the U.S. and returned to their country of origin. Residence in a correctional facility impacts completion of treatment rates negatively. 130 out of 1158 Contacts with LTBI 112 out of 130 Initiated LTBI Treatment 74 out of 112 completed LTBI Treatment Contact investigations are an essential component of TB control. Contact investigations identify, examine, and evaluate all persons who are at risk of TB infection due to recent exposure to a diagnosed infectious case; sputum-smear positive cases are the priority for contact investigations. This process facilitates new case finding which in turn allows for early detection and treatment of new infections. In some cases, it may even prevent disease. 7 The LHDs are reponsible for conducting contact investigations or coordinating with responsible parties outside local public health to ensure contact investigations are completed. The last year in which contact information data is available is 2013 due to the length of time to complete treatment XV. International Referrals and Class Bs Evaluation of Class B Referrals, Arizona, 2015 265 Class B 1 Referrals 46% Evaluated within 30 days 31.3% Completed Evaluation within 90 days 59.2% Initiated Evaluation Regardless of Time 91.7% completed Medical Evaluation regardless of time Treatment of Class B Referrals, Arizona, 2013 11 Completed 24 Started Therapy 51 Recommended for Therapy 86 diagnosed with LTBI Immigrants and refugees traveling to the U.S. are evaluated for TB as part of the admission process, and are assigned a classification according to the status of their disease. Class A individuals have TB disease and have been granted a waiver. Class B1 includes individuals with non-infectious pulmonary TB disease with negative acid-fast bacilli sputum smears and cultures. Class B1 also includes extra pulmonary TB cases. Class B2 individuals have positive skin tests but have negative evaluations for active TB disease. Class B3 individuals are recent contacts of a known TB case. Class B1 individuals are the priority for the Department. The CDC Division of Global Migration and Quarantine notifies the Department of all Class B individuals entering the state. The Department forwards these referrals to the LHDs where the individual will reside. The LHDs provide medical evaluation and treatment. The transitory nature of the immigrant and refugee population makes it difficult to initiate or complete evaluations and treatment for these individuals. The Department is developing strategies to overcome these barriers. International Referrals and Case Management The Department coordinates with international referral agencies to ensure continuity of care for individuals with TB or suspected of having TB who return to their home country. CureTB facilitates the referral process with public health officials in Mexico and is expanding to other countries. Migrant Clinicians Network (TBNet) facilitates the referral process for all countries including Mexico. Close collaboration with these entities has positively impacted completion of treatment. Also, in 2015, both agencies were given access and trained to use Arizona’s electronic communicable disease surveillance system, Medical Electronic Disease Surveillance Intelligence System (MEDSIS). 8 This has further improved communication and collaboration. Border Health Activities To ensure continuity of care for individuals being treated for TB who are repatriated to Mexico through Nogales and San Luis, Arizona, the Department coordinates “Meet and Greets.” The Meet and Greet involves transferring these individuals from Arizona and federal law enforcement authorities to Mexican law enforcement and public health authorities. The Meet and Greet protocol developed in 2007 has resulted in better coordination of inmates returning to Mexico. The protocol includes working closely with Pinal County Public Health, ADHS Office of Border Health, correctional facilities, LHDs, Sonoran partners, CureTB, and ICE authorities. In 2015, the Department arranged fifteen Meet and Greets through the port of Nogales and one through the port of San Luis. The Department is collaborating with Sonoran public health officials to improve communication and completion of treatment for binational TB cases. MEDSIS is available for use in Sonora, Mexico as well. XVI. Conclusion The Department continues to partner with LHDs, federal agencies, correctional facilities, and the international community to prevent and control TB in Arizona. These partnerships have improved treatment completion, data quality, and communication between different jurisdictions. Continued close collaborations with LHDs and outside partners will prevent further spread and curb the emergence of drug-resistant TB. 9